13 year old male presented with complaints of fever, vomiting, loss of appetite since 5 days.

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A 13 year old male student by profession, resident of Nalgonda , presented(3rd jan) with chief complaints of fever,   vomiting , loss of appetite since 5 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 5 days back, then he developed high grade fever that was associated with chills and rigors. He also had single episode of vomiting on the day one, which was non-bilious, non-projectile , and had food as content. Vomiting subsided the next day.

As the fever did not subsided patient was taken to RMP , where he was given 

-TAB PCM(500mg) once a day.

-TAB chloroquine(250mg) twice a day.

-TAB voveron  thrice a day.

As the fever did not subside patient was put on TAB cefixime(200mg) twice a day.

On the day 5 (4th jan)the patient had 5 episodes of vomiting which was non-bilious, non-projectile , and food as content. It was associated with abdominal pain which was diffuse  and colicky type.

No H/O loose stools , hematuria , petechia.

Fever subsided on the 2nd day of admission.

PAST HISTORY 

there were no similar complaints in the past .

No H/O of hypertension, diabetes, TB, asthma.

Surgical history:- the patient had undergone appendicectomy surgery 2 months back.

FAMILY HISTORY 

No significant family history.

PERSONAL HISTORY 

DIET:- mixed

APPETITE :- decreased 

SLEEP:- adequate 

BOWEL AND BLADDER HABITS:- regular

ADDICTIONS:- none.

GENERAL EXAMINATION 

Patient is conscious , coherent and cooperative and well oriented with time place and person.

There were no signs of pallor , icterus, cyanosis, clubbing lymphadenopathy and oedema.

VITALS

Temperature:- afebrile.

Heart rate :- 88 bpm

Respiratory rate:- 12 cpm

BP:- 110/80 mm of hg

Spo2:- 98%

SYSTEMIC EXAMINATION 

CVS:- S1, S2 heard.

Respiratory system:- bilateral air entry present , vesicular breath sounds are heard.

P/A :- soft, mild diffused tenderness.

CNS :- no abnormalities detected.

INVESTIGATIONS ORDERED 

Hemogram 

Serum electrolytes 

M.P strip test

Ns1 antigen test

CUE

USG-abdomen 

 

    

PROVISIONAL DIAGNOSIS 

Viral pyrexia with bicytopenia(leukopenia and thrombocytopenia).

TREATMENT 

IVF:- NS, RL, DNS(UO+30ml/hr).

INJ. PANTOP(40mg) IV/once a day.

INJ. ZOFER(2mg) IV/ thrice in a day.

INJ. NEOMOL(100ml) IV , IN CASE OF INCREASE IN TEMP 

TAB. PCM (500mg) thrice in a day.